The next step in the process of seeking to change a decision of your HMO to deny medical care is for you to utilize the grievance procedure set forth in your provider agreement. It is important that you pursue your grievance precisely in accordance with the terms of your contract, including timing and other specific requirements.
If you fail to do this, your HMO will assert that you are not entitled to the medical services you are seeking because you did not comply with the terms of your contract. If you have any doubt about what is required in order to comply with your contract, get help immediately from someone who is competent to advise you of what you need to do.
The review procedure established by most HMOs consists of an in-house review first, followed by a review by a designated state agency. Assuming that you have already spoken with a representative at your HMO and written the certified mail, return receipt requested letter discussed, the only thing you need to do regarding the in-house review is make sure that you have complied precisely with the requirements of your provider agreement. This may consist simply of designating the materials you have already supplied as a formal appeal. If you have any doubt that you have followed the review procedure correctly, check with the HMO and confirm what you are doing in a subsequent letter to it.
You may want to consider obtaining the assistance of a lawyer at this point, depending upon the seriousness of the particular matter. If you do choose to do this, prepare a complete chronology of all of your dealings in the matter so far. This will enable the lawyer to understand the full scope of the matter very quickly and will save you money in legal fees.
You may also find, in some instances, that the insurance broker who provided you with coverage, or the insurance broker for your employer, if that is how you obtained coverage, may be of assistance to you. Some brokers are quite adept at convincing medical insurers of all types to authorize particular services. This is particularly true when the broker has a good deal of business with the insurer, such as with an HMO.